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Schools struggle to provide dental health safety net

March 31, 2013

March 31, 2013

Students learn how to care for their teeth and receive preventive care at a dental clinic at James Madison Middle School in Oakland. Credit: Alameda County Public Health Department

As California educators grapple with boosting student achievement across economic lines, the teeth of poor children are holding them back.

Hundreds of thousands of children suffering from dental disease, some with teeth rotted to the gum line, are presenting California school districts with a widespread public health problem.

Increasingly, dental health advocates are looking to school districts to help solve the crisis. Innovative oral health care projects have been launched around the state, including on-campus dental clinics in the Oakland Unified School District, the El Monte City School District and the San Diego Unified School District, that provide students with no-cost dental screening or treatment. Third-party insurance companies are billed whenever possible.

Dental disease is at “epidemic” levels among California children, according to the U.S. Surgeon General, and low-income children are disproportionately affected. They are 12 times more likely to miss school because of dental problems than children from higher-income families, according to a 2008 report by the Healthy States Initiative, a coalition sponsored by the Council of State Governments to study state health problems.

“The issue is huge,” said Gordon Jackson, director of the state Department of Education’s Coordinated Student Support and Adult Education Division, which oversees health, counseling and other support programs provided at schools. “Tooth decay remains one of the most chronic diseases for children and adolescents. As we’re having the conversation about California’s future and student academic achievement, we have to have a conversation about oral health as well.”

But many districts lack the resources, or balk at being asked to provide dental care on top of a rigorous curriculum. In a school day packed with academics, and with schools under pressure to improve test scores, taking kids out of class to see the dentist or hygienist can be a tricky negotiation between health providers and school principals.

“It’s a great idea to bring universal prevention programs of all types, including dental, to schools,” said Kimberly Uyeda, director of student medical services for the Los Angeles Unified School District. “Whether there’s enough time in the day is another question.”

Lost revenue

Still, schools have a vested interest in helping solve the problem.

Dental problems keep California students out of school an estimated 874,000 days a year, costing schools about $29.7 million in lost attendance based-funding, according to the 2007 California Health Interview Survey, an ongoing statewide survey by the Center for Health Policy Research at UC Los Angeles. The study is still considered the benchmark for children’s oral health.

Credit: Lillian Mongeau, EdSource Today

Dental health also affects student performance. Students with toothaches were almost four times as likely to have a lower grade point average than students with healthy teeth, according to a 2012 study by the Herman Ostrow School of Dentistry at the University of Southern California.

Advocates say the dental health crisis is exacerbated by the failure of Medi-Cal’s dental program, called Denti-Cal, to adequately serve low-income children, lack of funding for a state school-based dental disease prevention program for low-income children, and the lack of money to enforce existing state laws requiring oral screenings and preventive care for school children.

School-based dental clinics can play a large part in the solution, given the holes in the state’s safety net. One model is to house dental care inside a school-based medical clinic. Some 61 school-based health clinics, out of about 200 in the state, offer dental disease prevention, which means having a dental hygienist who screens and refers students out to full-scale dental clinics. Of these 61 school heath clinics, 36 offer full dental treatment services and can provide on-site oral health care to students.

Outside of a school setting, finding a dentist who accepts Denti-Cal is a significant obstacle for low-income children. California’s reimbursement rates to Denti-Cal dentists are among the lowest in the nation, according to a January 2013 report by The Children’s Partnership, a nonprofit that studies dental care in California. And according to a recent survey of 300 dentists conducted by Barbara Aved Associates, a Sacramento-based health consulting firm, low reimbursement rates are the main reason why dentists don’t sign up with Denti-Cal.

The numbers of low-income children who need care are expected to increase as of January 2014, when the Affordable Care Act will give all California children access to dental insurance for the first time. Children covered by the Affordable Care Act, combined with the transfer of children from the Healthy Families Program to Medi-Cal coverage this year, will swell enrollment in Denti-Cal to nearly 5 million. This means that nearly half of California’s children will be Denti-Cal patients, according to The Children’s Partnership report.

The implications are clear, advocates say. “You’ve got to bring the services to the children,” said Roseann Mulligan, chair of Dental Public Health and Pediatric Dentistry at the Ostrow School of Dentistry and one of the authors of the study about oral health and student achievement.

Reaching students

A number of districts are doing just that. Some of the dental services are financially self-sustaining through billing to third-party insurers, while others rely on grants and partnerships. The goal is for all clinics to become self-sustaining.

Inside the sleek new student health center housed at James Madison Middle School in Oakland, dental hygienist Linda G. Cannon beams her headlamp into the mouths of hundreds of students from the middle school and nearby Sobrante Park Elementary School. Two days a week, during physical education class period or the “sixth period” extra time, students spend about 50 minutes in the baby-blue dental chair. With the whoosh of the suction tool as a soundtrack, Cannon screens for decay, cleans teeth, applies fluoride varnish, which can help prevent tooth decay, and applies tooth sealant, which is an effective barrier to cavities, particularly on molars. The clinic, which doesn’t provide fillings or other restorative dentistry, accepts dental insurance and Denti-Cal, and provides free service to the uninsured. Services are funded by the Alameda County Public Health Department and The Atlantic Philanthropies, a New York-based private foundation.

Of the more than 400 students students screened at James Madison in the last two years, nearly three quarters of elementary school students and just over half of middle school students showed signs of tooth decay, Cannon said.

Another model is a mobile dental clinic that travels to schools. In the San Diego Unified School District, the La Maestra Mobile Health Clinic, which includes dental services, began operating in fall 2012 to provide fillings and restorative dentistry to students at the Hoover Cluster of schools: 10 elementary schools, two middle schools, and one high school in the City Heights neighborhood, an area of high need.

Students receive initial screenings and preventive care at dental clinics housed in school health centers in the Hoover Cluster. For treatment, they go to the mobile van, which includes two “operatories” – full stations with dental chairs, suction devices, drainage, drills and x-ray equipment – and a comfortable reception area.

“What we are trying to do is make it a positive experience,” said Dorothy Zirkle, a consultant for Price Charities, a nonprofit dedicated to improving the quality of life for children in City Heights. “Our kids have a high need for multiple fillings. We need to build trust.”

All services are no-cost, with providers seeking reimbursement from insurers when possible. Among the organizations funding the facilities and services at the mobile dental clinic are La Maestra Community Health Centers, private foundations including the City Heights Partnership for Children, and the Health Resources and Services Administration of the U.S. Department of Health and Human Services.

A third model is a partnership with a nearby dental college to offer expanded services for students. In the El Monte City School District, students receive comprehensive dental care at two dental clinics housed in elementary schools, as well as from a mobile dental unit.

The dental clinics, which opened in 2012, rely on the services of dentists and dental students from the Western Universityof Health Sciences College of Dental Medicine.

Advocates say these programs and others like them are key to helping solve the dental health crisis facing California students.

Data that show the connection between oral health and student achievement will help persuade districts to support school-based dental care, said Maryjane Puffer, executive director of the Los Angeles Trust for Children’s Health, a nonprofit founded to serve students in LA Unified.

“School districts are eager to find a way to help kids stay in school and achieve,” she said.

Comments Policy

Paul4 years ago4 years ago

This isn't at all what I have said, El.
With such high percentages of students qualifying for free or reduced-price school lunch, Healthy Families (or its successor), subsidized day care, and so on, aren't you suspicious of some parents' economic choices?
Thirteen years (kindergarten through Grade 12) of free lunch and Healthy Families insurance would indicate permanent family financial problems. Everyone -- unprepared parents, deprived children, overstretched helping professionals (teachers, social workers, etc.) and taxpayers -- loses … Read More

This isn’t at all what I have said, El.

With such high percentages of students qualifying for free or reduced-price school lunch, Healthy Families (or its successor), subsidized day care, and so on, aren’t you suspicious of some parents’ economic choices?

I am not socially conservative (social conservatives are in the paradoxical position of opposing family planning while also opposing social services), but no government program has succeeded, or ever could succeed, in creating completely equal outcomes for economically disadvantaged children.

Waiting a few years for better training, a stable job, and a co-parenting relationship or a social suppprt network can make all the difference for one’s children.

Paul4 years ago4 years ago

Hello, CarolineSF.

Children should absolutely receive the services that they need. In cases where the parents have not done as much as possible to be responsible, the costs should be recovered over the long term, and with the same legal precedence as child support.

I am suggesting that temporary versus ongoing use of services is a good marker of parental responsibility.

CarolineSF4 years ago4 years ago

But then, Paul, should the children be denied services because their parents made bad decisions?

Paul4 years ago4 years ago

El's point that parents' incomes can change after a child is born underscores the importance of approaching parenthood as a rational economic decision.
Smart future parents delay parenthood, save up money, create some measure of employment stability by acquiring useful skills, and cultivate a support network (extended family; close friends who are also young parents; or a group such as a local labor union or a social order). They also purchase appropriate term life and disability … Read More

El’s point that parents’ incomes can change after a child is born underscores the importance of approaching parenthood as a rational economic decision.

Smart future parents delay parenthood, save up money, create some measure of employment stability by acquiring useful skills, and cultivate a support network (extended family; close friends who are also young parents; or a group such as a local labor union or a social order). They also purchase appropriate term life and disability insurance, products which are available at a reasonable cost from employers, unions, government (CASDI, SS) and/or private insurers.

If there is an income disparity, marriage/registered domestic partnership is advisable, as this creates a presumption of parentage and gives the spouse with the lower income a strong legal claim on the higher-income spouse’s current (during the relationship) and future (after the dissolution of the relationship) earnings.

Lastly, smart future parents exercise moderation, opting for one or two children unless there are ample financial resources.

Parents who have taken as many of these steps as possible should certainly be entitled to temporary subsidized daycare, free lunch, and in-school health services if fortunes change. Otherwise, it’s just bad planning, and the parents are squarely to blame for the pain that they have caused their children and for the extra expenses that they have imposed on the larger society.

el4 years ago4 years ago

Without a million dollars in the bank, you’re just one health care crisis away from being an irresponsible parent. Most of us just get lucky.

el4 years ago4 years ago

I am appalled by the graphic's assertion that 24% of children have never seen a dentist. The paper is behind a paywall, so I couldn't dig into it to see if that was national vs California, or at what age that cut off. It's ridiculous and horrifying that this is so. I note that it matches the percentage of US children living in poverty (though is less than the percentage of children who are in … Read More

I am appalled by the graphic’s assertion that 24% of children have never seen a dentist. The paper is behind a paywall, so I couldn’t dig into it to see if that was national vs California, or at what age that cut off. It’s ridiculous and horrifying that this is so. I note that it matches the percentage of US children living in poverty (though is less than the percentage of children who are in poverty during some part of their childhood).

I am sympathetic to Involved Parent’s irritation that this shouldn’t be a school function. I agree: I’d like to see all kids have universal access to health care via the health care system. It’s ridiculous that we can’t see our way to do this, that we’re so intent on punishing some imagined strawman that we’re willing to sacrifice kids. Realistically, if I were a very low income parent, my child would have housing and food and other things before dentistry too. The economics of the situation are not kind, and the access to dental services for low income families is terrible.

An additional factor for many of these families is probably transportation. Our community used to have a local dental clinic and community health center; it was defunded during the state budget crisis because there is another within 20 miles. However, public transportation was also a casualty. When dentists are only open during business hours and are some distance away, getting there can require taking a whole day off work… and school, because of course there are very few appointments, if any, available outside of those hours. It’s another potential advantage of having say a community dental center colocated with a school.

Finally, I’d like to point out that the salary a family is earning when a child is conceived is not actually guaranteed for life.

D4 years ago4 years ago

“The cost of ongoing (as opposed to emergency/temporary) free or reduced-price school lunches, school-based medical care, subsidized daycare, and other non-educational school services should be recovered from parents, over the long-term if necessary and through wage garnishment if absolutely necessary. Having children is a major economic decision, one entered into far too lightly by many people.”

BRAVO!!!!! Especially the part “recovered from the parents” Watch how many kids magically can bring their own lunch then.

Paul4 years ago4 years ago

I agree with you, Navigio: students can't learn very effectively when their basic physical needs are not being met. On the other hand, Involved Parent has a point: parents (should) bear ultimate responsibility for the physical wellbeing of their own children.
Universal health care -- not the Band-Aid approach currently being implemented in the US -- is the bottom line. It is interesting to note that many universal health insurance systems, including the provincial health insurance … Read More

I agree with you, Navigio: students can’t learn very effectively when their basic physical needs are not being met. On the other hand, Involved Parent has a point: parents (should) bear ultimate responsibility for the physical wellbeing of their own children.

Universal health care — not the Band-Aid approach currently being implemented in the US — is the bottom line. It is interesting to note that many universal health insurance systems, including the provincial health insurance plans in Canada, exclude all dental care and most vision care. Decades ago, Saskatchewan, the birthplace of universal health care in Canada, dismantled its school-based dental service program.

In the absence of universal and comprehensive health insurance, school-based clinics are essential. Existing US privacy laws are adequate to protect parents who have made private arrangements for their children’s health care. Laws also protect older youths who wish to receive sensitive health services, such as contraception, without involving their parents.

To return to Involved Parent’s argument, and without wanting to embrace a neo-conservative agenda in any way, I would like to see mechanisms that force parents to take economic responsibility for their children. The cost of ongoing (as opposed to emergency/temporary) free or reduced-price school lunches, school-based medical care, subsidized daycare, and other non-educational school services should be recovered from parents, over the long-term if necessary and through wage garnishment if absolutely necessary. Having children is a major economic decision, one entered into far too lightly by many people.

navigio4 years ago4 years ago

Well, I think there are two issues here: first that some kids dont go to the dentist (whether or not they happen to have insurance or access) and second that there is lost revenue (and potentially associated educational loss) due to absence or distraction because of the dental problem.
In the first case, the 'cost' can be recovered to some or all extent because third parties are sometimes billable. But for those kids who actually have … Read More

Well, I think there are two issues here: first that some kids dont go to the dentist (whether or not they happen to have insurance or access) and second that there is lost revenue (and potentially associated educational loss) due to absence or distraction because of the dental problem.

In the first case, the ‘cost’ can be recovered to some or all extent because third parties are sometimes billable. But for those kids who actually have access but dont go, the idea is to ‘take the care to the kids’. The alternative in that case is they already forgo proper care, so resisting that kind of support does not seem like it would convince any parents to modify their behavior.

In the second case, regained revenue can also help to recover costs, if not only partially. However, that is obviously only part of the story. If the loss of attendance and concentration due to medical problems impacts achievement, then these costs are also regained, albeit only morally (and perhaps financially longer-term).

I still think the fact that we measure districts for elements of education they have no control over (achievement gap increase over summer or before kindergarten; poverty, and all its associated negative impacts, etc) that education policy will continue to try to expand its scope to give it more control over those factors.

As an example in this case, if we had a way of holding schools harmless (both financially and academically) for the impact of tooth decay, I expect we would never see policies like this within the public education scope (we’d see them, just in other areas of society, because there is still the moral concern). I think this is the same reason pre-k care is becoming more and more of a public education issue.

And yes, involved parent absolutely has a point. I just think the point was different than the one made in the article. And while I agree with universal health care, I still think its valid to question whether people will actually use it (and if they dont, what the impact will be).

Personally, I have thought a lot about the social engineering front and, as I like to say, ‘you cant legislate morality.’ 🙂 I do believe you can coerce certain behavior with financial or criminal threats or incentives, but its not really the same thing as what we think being a good person means (even though we want the outcomes to be the same). Furthermore, I have much less of a problem directly trying to coerce adults into certain behavior because they are, after all, adults and have control over their own actions and pretty much understand what is happening to them. However, when a policy (intentionally) negatively impacts kids in order to coerce a certain behavior from the parent, I have to draw the line. Especially when the claim already is that the parents dont care or are irresponsible. That seems only to cement the child’s demise.

I also passionately believe what works much better than financial incentives is education. When people really understand the impact of their own actions, they generally change (there are probably a few for whom that does not apply, but those are also immune to the other type of coercion anyway). In the long run, less education is clearly not the answer, since it is arguably exactly that which creates more people whom others feel need to be coerced.

Many years ago, someone said to me, ‘the harder you push against a wall to try to move it, the less freedom you yourself have to move.’ It feels like creating policies that punish children for the behavior of their parents is just pushing harder and harder against a really big, immovable wall.

An Involved Parent4 years ago4 years ago

navigio - Than the logical outcome is for the School Districts to build boarding houses and for these kids to be made Wards of the state....therefore they'll all get timely care and thus they won't miss school - right? Then the schools can feed these kids 3 squares a day, make sure they get annual physicals, bi-annual dental care, clean clothes, properly fitting shoes....test scores will soar!!! It's absurd - just as absurd … Read More

navigio – Than the logical outcome is for the School Districts to build boarding houses and for these kids to be made Wards of the state….therefore they’ll all get timely care and thus they won’t miss school – right? Then the schools can feed these kids 3 squares a day, make sure they get annual physicals, bi-annual dental care, clean clothes, properly fitting shoes….test scores will soar!!! It’s absurd – just as absurd as schools getting into the health care business! As it is more and more resources go to the poorest schools, which have the poorest test scores, in a futile attempt to raise performance. Meanwhile, more and more “extras” get cut!!!

Julia Lear4 years ago4 years ago

In addition to providing services, another role school-based health centers might fill is educating parents about the importance of good oral health care for their children. In a recent study on children's oral health, a colleague and I learned that 20+ national oral health experts believe that the main reason for persistent, intractable barriers to children's access to care is that oral health is not viewed as a priority. While competing needs for limited dollars … Read More

In addition to providing services, another role school-based health centers might fill is educating parents about the importance of good oral health care for their children. In a recent study on children’s oral health, a colleague and I learned that 20+ national oral health experts believe that the main reason for persistent, intractable barriers to children’s access to care is that oral health is not viewed as a priority. While competing needs for limited dollars contributes to the problem, as one foundation official put it, “Unfortunately, in our country too many people accept losing teeth as inevitable.” To read the study, go to StrengtheningChildren’s Oral Health: Views from the Field. http://www.healthinschools.org/School-Based-Oral-Health.aspx

An Involved Parent4 years ago4 years ago

I understand the need - however - at some point schools need to focus on education - and stop trying to provide anything/everything a child needs. Parents need to find the resources, and provice for their children.
How about schools focus on education...and not providing, food, medical care, clothing..and other things that are a PARENT'S responsibility?
It seems the more the schools do - the less actualy education is happening!!! I don't need the school … Read More

I understand the need – however – at some point schools need to focus on education – and stop trying to provide anything/everything a child needs. Parents need to find the resources, and provice for their children.

How about schools focus on education…and not providing, food, medical care, clothing..and other things that are a PARENT’S responsibility?

It seems the more the schools do – the less actualy education is happening!!! I don’t need the school to serve as parents, and subsituting their judgement for my own. Yet more and more it seems that is what’s happening….and what’s frustrating to me is when they “screen” then they feel entitled to know what follow-up care suggests/says/did……last time I checked – my child’s medical needs/care begins and ends with my provider and me.

I don’t think in school chinics are the answer at all…what is needed is valid health care insurance /universal care and the parents to take their kids to the providers of their choosing! I’d much rather see my district put back in the extracuriculars such as art, science, and sports….than a medical or dental clinic – despite the supposed need. AT some point, schools need to be schools, and not one stop centers for all of a kid’s needs.

navigio4 years ago4 years ago

The goal is not to create something that takes away from the ability to educate, rather just the opposite by making sure kids are in school more. One of the side effects of holding schools more accountable is that they will try to take control of more of the outside factors that work against their ability to education children, until, of course, we take those things into account in our accountability metrics (we pretty much … Read More

The goal is not to create something that takes away from the ability to educate, rather just the opposite by making sure kids are in school more. One of the side effects of holding schools more accountable is that they will try to take control of more of the outside factors that work against their ability to education children, until, of course, we take those things into account in our accountability metrics (we pretty much dont).

Obviously its possible to say the parent should be responsible for medical needs. But if that does not happen (due to parent or societal behavior) is the proper response simply, ‘too bad’ ?

el4 years ago4 years ago

I'm glad to see this - it's what's right for the kids - and yet I'm disgusted in our state and our nation that we deprive kids of needed dental care.
You know how sometimes people will say that we spend more on "education" than other nations? This is part of the reason why - because we account billions of dollars of health care costs to education rather than to health care. So people simplistically take … Read More

I’m glad to see this – it’s what’s right for the kids – and yet I’m disgusted in our state and our nation that we deprive kids of needed dental care.

You know how sometimes people will say that we spend more on “education” than other nations? This is part of the reason why – because we account billions of dollars of health care costs to education rather than to health care. So people simplistically take a $ per student number in different nations, and compare them, unaware or uninterested in the fact that we are buying quite a lot of different services with those dollars per student than other nations do.

(And to tie this to my last comment… where is StudentsFirst in advocating for universal dental care for American kids, hmm?)